Dysphagia, Oral Care and Nutrition/Hydration. Nutrition Considerations. Nutrition Considerations 5/26/2017. David Beattie, SLP Anita Lopes, RD

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1 Dysphagia, Oral Care and Nutrition/Hydration David Beattie, SLP Anita Lopes, RD Nutrition Considerations BEST PRACTICE GUIDELINES: The swallowing, nutritional and hydration status of stroke patients should be screened as early as possible, ideally on the day of admission, using validated screening tools (Evidence Level B). Abnormal results from the initial or ongoing swallowing screens should prompt referral to a speech language pathologist, occupational therapist and/ or dietitian for more detailed assessment and management of swallowing, nutritional and hydration status (Evidence Level C). (Casaubon LK, Boulanger JM, 2015) Nutrition Considerations BEST PRACTICE GUIDELINES: An individualized management plan should be developed to address therapy for dysphagia, nutrition needs and specialized nutrition plans (Evidence Level C). Stroke patients with suspected nutritional concerns, hydration deficits, dysphagia or other comorbidities that may affect nutrition (such as diabetes) should be referred to a dietitian for recommendations: a. to meet nutrient and fluid needs orally while supporting alterations in food texture and fluid consistency (Evidence Level B) (Casaubon LK, Boulanger JM, 2015) 1

2 Nutrition Considerations BEST PRACTICE GUIDELINES: b. for enteral nutrition support (nasogastric tube feeding) in patients who cannot safely swallow or meet their nutrient and fluid needs orally. The decision to proceed with tube feeding should be made as early as possible after admission, usually within the first three days of admission in collaboration with the patient, family (or substitute decision maker) and interprofessional team (Evidence Level B). (Casaubon LK, Boulanger JM, 2015) Malnutrition Malnutrition includes both the deficiency and excess (or imbalance) of energy, protein and other nutrients. Undernutrition in the focus in clinical practice and affects body tissues, functional ability and overall health In hospitalized patients, undernutrition is often complicated by acute conditions (e.g. a trauma), infections and diseases that cause inflammation. Such complications worsen undernutrition and make it more challenging to correct due to extensive physiological changes and increased nutritional needs when appetite is decreased. Adapted from AW McKinlay: Malnutrition: the spectre at the feast. J R Coll Physicians Edinb 2008: Malnutrition in Stroke Malnutrition is an independent predictor of poor outcomes after stroke (FOOD Trial, 2003) and an independent predictor of mortality, LOS, and hospitalization costs at 6 months post stroke (Gomes, Emery & Weekes, 2015) The overall odds of being malnourished are higher among subjects who were dysphagic vs not(foley et al., 2009) 20% patients become more malnourished in the first weeks after a stroke (Yoo et al., 2008) 2

3 Canadian Nutrition Screening Tool (CNST) (Laporte M, Keller H, Payette H et al, 2014) Ask the patient the following questions* Yes No Yes No Have you lost weight in the past 6 months WITHOUT TRYING to lose weight? Have you been eating less than usual FOR MORE THAN A WEEK Two YES answers indicate nutrition risk * If the patient is unable to answer the question a knowledgeable informant can be used to obtain the information. Canadian Malnutrition Task Force nutritioncareincanada.ca/ Dehydration?Assessing Dehydration? monitoring of fluid intake dry mouth / symptoms of thirst urine colour, volume or osmolality blood pressure and heart rate urea: creatinine ratio plasma osmolality, saliva osmolality (Hooper et al., 2015) 3

4 Dehydration and Stroke Dysphagia prevalent in 56% of dehydrated patients vs 30% of hydrated patients Associated with increased mortality (Rowat, Graham & Dennis, 2012) Factors impacting oral intake following stroke Physical Organizational Patient Can t reach meal tray Repositioning patient for meal Need help at meals (set-up, feeding, etc) Polypharmacy Lack of feeding assistance Inappropriate menu choices Palatable food Timings of meals Interruptions to mealtimes Rushed mealtimes Ward environment Staff knowledge Dysphagia Drowsiness Hemiparesis Visual impairment Cognitive impairment Pain Poor dentition Sore or dry mouth Oral thrush Changes in taste and smell Low appetite Depression GI Issues Anxiety 4

5 What to do? Nutrition Care Plan 1)Nutrition counsellingencouragement/education 2)Food fortification Liberalizing diets 3) Organizing meal time assistance/protected meal times 4) Nutrition supplementation 5) Enteral Nutrition 4)Supplementation? Yes but, only if malnourished Across the board supplementation was associated with a 1% to 2% absolute benefit from oral supplements. (Dennis et al, 2005a) Oral supplements can increase the amount of energy and protein patients consume, and prevent unintentional weight loss (Gariballa et al. 1998) Individualized nutritional support to older stroke patients in hospital was beneficial for maintaining an adequate body mass and body composition the first week and seemed to have a preventive effect on fat loss among women, after three months. (Ha 2010) Nutritional supplementation was associated with reduced pressure sores, and, by definition, increased energy intake and protein intake. (Geeganage et al, 2012) 5)Enteral Nutrition? For patients who cannot obtain nutrient and fluid needs orally, enteral nutrition may be required. The decision to use enteral support should be made within the first seven days post stroke. PEG feeding was associated with an absolute increase in risk of death of 1.0% and an increased risk of death or poor outcome of 7.8% at 6 months. Early tube feeding was associated with non-significant absolute reductions in the risk of death or poor outcome and death at 6 months. (Dennis et al. 2005b) 5

6 In Summary 1)Is patient at risk of malnutrition? 2) Refer to a dietitian 3) Implement nutrition care plan References -AW McKinlay: Malnutrition: the spectre at the feast. J R Coll Physicians Edinb. 2008; 383: Bhalla A, Sankaralingam S, Dundas R, Swaminathan R, Wolfe CD, Rudd AG. Influence of raised plasma osmolality on clinical outcome after acute stroke. Stroke. 2000;31: Kelly J, Hunt BJ, Lewis RR, Swaminathan R, Moody A, Seed PT, et al. Dehydration and venous thromboembolism after acute stroke. Q J Med. 2004;97: Casaubon LK, Boulanger JM, on behalf of the Acute Inpatient Stroke Care Writing Group. Acute Inpatient Stroke Care Module In Lindsay MP, Gubitz G, Bayley M, and Smith EE (Editors) on behalf of the Canadian Stroke Best Practices and Advisory Committee. Canadian Stroke Best Practice Recommendations, 2015; Ottawa, Ontario Canada: Heart and Stroke Foundation. -Dennis M1, Lewis S, Cranswick G, Forbes J; FOOD Trial Collaboration. FOOD: a multicentre randomised trial. Lancet. 2005; Feb 26-Mar 4;365(9461): Foley NC, Martin RE, Salter KL, Teasell RW: A review of the relationship between dysphagia and malnutrition following stroke. J Rehabil Med 2009, 41: FOOD Trial Collaboration. Poor Nutritional Status on Admission Predicts Poor Outcomes After Stroke. Stroke. 2003;34: , originally published June 1, Geeganage C, Beavan J, Ellender S, Bath PM. Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev. 2012;10:CD doi: / CD pub2 -Gomes F, Emery P, Weekes CE. Risk of Malnutrition on admission predicts mortality, length of stay and hospitalisation costs. Stroke. 2014;45:ATP Ha, L, Hauge, T, Iverson, PO. Body composition in older acute stroke patients after treatment with individualized, nutritional supplementation while in hospital. BMC Geriatrics. 2010; 10:75 References --Hooper L, Abdelhamid A, Attreed NJ, CampbellWW, Channell AM, Chassagne P, Culp KR, Fletcher SJ, FortesMB, Fuller N, Gaspar PM, Gilbert DJ, Heathcote AC, Kafri MW, Kajii F, Lindner G, Mack GW, Mentes JC, Merlani P, Needham RA, Olde Rikkert MGM, Perren A, Powers J, Ranson SC, Ritz P, Rowat AM, Sjöstrand F, Smith AC, Stookey JJD, Stotts NA, Thomas DR, Vivanti A, Wakefield BJ, Waldréus N, Walsh NP, Ward S, Potter JF, Hunter P. Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people.cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD Laporte M, Keller H, Payette H et al. Validity and Reliability of the new Canadian Nutrition Screening Tool in the real-world hospital setting. European Journal of Clinical Nutrition advance online publication, December 2014; doi: /ejcn Rowat A, Graham C, Dennis M. Dehydration in hospital-admitted stroke patients: detection, frequency, and association. Stroke; a journal of cerebral circulation 2012;43: Yoo, Sung-Hee; Kim, Jong S.Undernutrition as a Predictor of Poor Clinical Outcomes in Acute Ischemic Stroke Patients. JAMA Neurology Arch Neurol. 2008;65(1):